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Abstract

While transgender and transsexual (trans) communities have been documented to experience high rates of suicidality, little attention has been paid to how this may vary based on experiences of social injustice. Using survey data from the Trans PULSE Project (n=433), we estimated that suicidal thoughts were experienced by 36% of trans Ontarians over the past year, and that 10% attempted suicide during that time. Moreover, we documented that youth and those experiencing transphobia and lack of support are at heightened risk. Suicidality varied greatly by medical transition status, with those who were planning to transition sex, but who had not yet begun, being most vulnerable. Recommendations are made for improving wellbeing in trans communities, through policy advocacy, service provision, access to transition care, and fostering accepting families and communities.

Corps de l’article

Background

Suicide represents a major cause of death worldwide, accounting for 1.5% of all deaths (Nock et al., 2008). Socio-demographic characteristics have been consistently associated with both suicide attempts and completed suicides, including variables such as age, race/ethnicity and gender (Nock et al., 2008; Pelkonen et Marttunen, 2003). Social groups found to have higher rates for attempted or completed suicide include: Indigenous people (Nock et al., 2008); youth (Nock et al., 2008; Pelkonen et Marttunen, 2003); seniors (Nock et al., 2008); sexual minority youth and adults (King et al., 2008); and men (Nock et al., 2008; Pelkonen et Marttunen, 2003). Though the variable of gender is frequently cited as a primary factor in suicide, databases from which population data are drawn do not record information about gender identity and therefore do not shed light on whether or how transgender / transsexual (trans) people are included in this data. Existing studies report only on individuals defined as “man/male” or “woman/female”, presumed to be cisgender people (non-trans) (Nock et al., 2008; Pelkonen et Marttunen, 2003).

In Ontario, recent estimates for depressive symptomatology among trans people were 61% for trans women (male to female) (Rotondi et al., 2011b), and 66% for trans men (female to male) (Rotondi et al., 2011a). There is evidence to suggest that these high prevalences of depression may be the result of emotional injuries incurred by trans people. For trans women, depression has been correlated with experiencing conflicted responses from others toward their trans identity (Nuttbrock et al., 2012) as well as with unemployment and transphobia – societal discrimination against trans people (Rotondi et al., 2011b). In one study, the correlation between experiences of gender abuse and major depression and suicidality among adolescent trans women was so strong that researchers reported that findings suggested a direct causal relationship between the two (Nuttbrock et al., 2010). In two studies examining correlates of having ever experienced suicidal thoughts or attempts, current or past suicidality was found to correlate to: a younger age (Clements-Nolle, Marx et Katz, 2006); lack of familial/parental support (Grant et al., 2011); experiences of transphobic discrimination (Clements-Nolle et al., 2006); precarious employment or unemployment (Grant et al., 2011); and experiences of physical or sexual violence (Clements-Nolle et al., 2006; Grant et al., 2011).

A limited number of studies have explored protective factors for trans people’s mental health and wellbeing. Increasing social support in one study was associated with reduced odds of depressive symptomatology in trans women, while sexual satisfaction was a protective factor for trans men (Rotondi et al., 2011b; Rotondi et al., 2011a). In another study, having one’s gender affirmed by others was predictive of lower rates of major depression in trans women (Nuttbrock et al., 2012). Among trans youth, having strong parental support for their gender was associated with a 93% reduction in recent youth suicide attempts (Travers et al., 2012).

The purpose of the current analysis was to estimate the prevalence of suicidal thoughts and attempts among trans people in Ontario, and to explore contributing risk and protective factors. Factors explored were based on findings from other studies as well as reports of lived experience by trans members of our community-based research team.

Methods

Participants and Sampling

Data were from the Trans PULSE Project, a CIHR-funded, community-based study of how social exclusion impacts that health of trans people. Trans PULSE was created as a partnership between community organizations, trans community researchers, and academic researchers. Survey data were collected (online or on paper) in 2009-2010 from trans people in Ontario age 16 or older (n=433). To be eligible to take the survey, participants had to indicate they were included within a broad definition of “trans”, but were not required to identify any particular way (e.g. transsexual), or to have begun or completed a transition – either a social transition to live in another gender, or a medical transition through hormones and/or surgeries.

Participant recruitment was undertaken using respondent-driven sampling (RDS), a network-based sampling method in which participants each recruited up to three additional participants, and recruitment networks were tracked (Heckathorn, 2002).

Measures - Suicidality

All data were self-reported. Participants were asked if they had ever seriously considered suicide or taking their own life, if this was related to being trans, and if it occurred in the past 12 months. Participants were also asked about suicide attempts, whether this occurred during the past 12 months, and whether they had seen or talked to a health professional following an attempt. They also reported their age at first suicide attempt.

Measures – Key demographics

Age – was coded as youth (age 16 to 24) versus older non-youth.

Gender spectrum – was coded into two categories: female-to-male versus male-to-female. When participants did not identify as male or female, identifying instead as genderqueer, Two-spirit, or other bigender or fluid identities, these individuals were included in either the female-to-male or the male-to-female category based on the combination of their natal sex and their gender identity. For instance, a respondent who reported a natal sex of “female” and a gender identity of “genderqueer”, would be placed in the female-to-male category.

Gender fluidity – included two categories: having a more conventional male/female identity versus a fluid identity (e.g. both male and female, neither, or something else).

Ethno-racial group – was composed of three groups. Participants were classified as Aboriginal if they indicated they were First Nations, Metis, or Inuit, or had another Aboriginal ethnicity. Non-Aboriginal participants were classified as white or racialized based on their responses to a question on ethno-racial background, a write-in question describing background, and indication as to whether or not they were perceived by others as a person of colour.

Birthplace – was classified on reporting that one was born in Canada versus elsewhere.

Social support – was assessed using the Medical Outcomes Study Social Support Scale (Sherbourne et Stewart, 1991). This was categorized into three groups: low (average support across 19 questions equals “some of the time” or less), medium (more than “some of the time” to “most of the time”) and high (more than “most of the time” to “all of the time).

Strong parental support for gender – was coded by combining self-report of “very strong” support experienced from a parent or parents and self-report of expectation of such support, among those who had not yet come out to their parents. Those with less than “very strong” support comprised a second category.

Transphobia – was assessed using a scale adapted by the Trans PULSE team from a homophobia scale by Diaz, Ayala, Bein, Jenne, and Marin (2001). This 11-item scale assessed a range of transphobic experiences, from police harassment to feeling that being trans hurt or embarrassed one’s family (Marcellin, Scheim, Bauer, et Redman, 2012). Transphobia was coded into three categories: low transphobia was defined as an average of “never” to “once or twice” across all items, medium transphobia as from more than “once or twice” average to a “sometimes” average, and high as an average ranging from more than “sometimes” to “always”.

Workplace discrimination – was defined as reporting ever experiencing any of the following: being fired from a job for being trans, being denied a job because of being trans, or turning down a job offer because of a lack of a trans-positive working environment, versus reporting none of these experiences.

Transphobic harassment and violence – was coded into three categories: self-report of physical or sexual assault for being trans; report of verbal harassment or threats related to being trans, but not of assault; and report of none of these forms of violence.

Medical transition status – was self-reported as having completed a medical transition (by one’s own definition of “completed”) involving hormones and/or surgery, being in the process of transitioning, planning to transition but not yet having begun, and either not planning, being unsure, or indicating that the idea of “transition” does not apply.

Statistical Analysis

Participant-reported information on social network size, along with information on recruitment patterns, was used to weight the data to produce estimated frequencies (Heckathorn, 2002) and 95% confidence intervals (Salganik et Heckathorn, 2004) that apply to the networked trans population in Ontario. Frequencies were calculated to describe experiences of suicidality overall, and within categories for key demographic variables and transition, transphobia and social exclusion variables. RDSAT software version 6.0.1 (Volz, Wejnert, Degani, et Heckathorn, 2007) was used to estimate weighted frequencies and 95% confidence intervals. While RDS sampling design limits some biases (for example, by limiting the number of participants one can recruit), these statistical methods adjust for biases related to differences in personal network size and different rates of recruiting among different groups. However, it is known that 95% confidence intervals may have less than 95% coverage (Salganik, 2006), and that the possibility remains for sampling biases that are unrelated to network size or differential over-/under-recruitment which cannot be adjusted for in analysis (McCreesh et al., 2012).

Since statistical tests such as chi-square tests are not available with these methods, variance recovery methods were used to produce tests for difference between proportions (Zou et Donner, 2008). Since p-values are not produced by these methods, they are not included, but in-text references to significant differences reflect this method.

Results

Frequencies for suicidal behaviour are presented in Table 1. We estimated that 77% of trans people in Ontario age 16 and over have ever seriously considered suicide, and that two-thirds of these persons would attribute that as related to their being trans. A very high proportion – 43% – had ever attempted suicide. Suicidality could emerge at a young age. Among those having ever attempted suicide, about one-third first did so at less than 15 years of age, and another one-third between ages 15 and 19 years. Within the past year, an estimated 36% of Ontario trans people had seriously considered suicide and 10% attempted.

Table 1

Suicidal thoughts and behaviour among trans people in Ontario, Canada: Weighted frequencies

In Table 2, we present frequencies for demographics of Ontario trans people, which are described in more detail elsewhere (Bauer, Travers, Scanlon et Coleman, 2012). We also present proportions within each demographic category that have seriously considered, or (separately) attempted suicide within the past year. Trans people were young, as a group, relative to the population, with about half falling on the male-to-female (MTF) spectrum and half on the female-to-male (FTM) spectrum. While most trans people held a primarily masculine or feminine identity, we estimated that about one in five (19%) had an identity that is both male and female, neither, or fluid. About one in four trans people was also a member of a racialized group: 7% Aboriginal and 16% non-Aboriginal, and one in five was born outside of Canada. Neither past-year suicidal consideration nor attempts differed significantly across demographic groups, with the exception of age. Among the most vulnerable groups were trans youth age 16 to 24 years, among whom 19% attempted suicide in the past year in comparison with 7% for those aged 25 years and older.

Table 2

Past-year suicidal thoughts and behaviour, by demographic background, among trans people in Ontario, Canada

Frequencies of transition, transphobia and social inclusion factors are displayed in Table 3, along with the proportions within each category considering and attempting suicide. Experiences of transphobia and lack of social inclusion and support were common. For example, 72% of trans people reported that they did not have “very strong” support from their parents for their gender identity or expression. About one-third had experienced some form of workplace discrimination that they would report as being because they are trans (note that much larger proportions had experienced these forms of discrimination, but were unsure if it was because they were trans). An estimated 20% of trans Ontarians had been physically or sexually assaulted because they were trans, with an additional 34% experiencing verbal harassment or transphobic threats.

Table 3

Past-year suicidal thoughts and behaviour, by social inclusion, transphobia and transition factors, among trans people in Ontario, Canada

Regarding medical transition status, the trans community could be split into quarters, with one quarter having completed a medical transition (which could involve different combinations of hormones and/or surgeries), one quarter being in process, one quarter planning to medically transition but not having begun the process, and the remainder either not planning to transition, being unsure, or feeling that the entire concept of transition did not apply to them.

Suicide risk was not evenly distributed, and varied greatly across the factors in Table 3. While consideration of suicide did not differ significantly by level of social support, those with high levels of social support were significantly less likely to attempt suicide than those with little support (2% versus 16%). Strong parental support for one’s gender identity or expression was associated with significantly lower past-year prevalences of both suicidal consideration and attempts. Those experiencing high levels of transphobia were more likely to consider suicide than those experiencing low levels. Interestingly, there was no suggestion that suicidality (either consideration or attempts) differed between those who had experienced trans-related workplace discrimination and those who had not. Transphobic violence, in contrast, showed strong associations. Among those who experienced transphobic physical or sexual violence, 56% had seriously considered suicide in the past year and 29% attempted; this contrasts with 28% and 4% respectively among those who experienced no transphobic assault, harassment or threats. Thus those who had experienced transphobic physical or sexual violence were seven times more likely to have attempted suicide in the past year. Finally, medical transition status was significantly associated with suicidality. Past-year serious consideration of suicide was highest among those who were planning a medical transition (55% considered suicide in this group), significantly higher than among those who had completed a transition, and among those who were not planning to or did not need to transition. Those planning or in process of medically transitioning sex also had very high prevalences of past-year attempts (27% and 18%, respectively), each significantly higher than prevalences of attempts in the other two groups: 1% among those who completed medical transition and 3% among those not planning a transition or for whom the concept did not apply.

Implications For Social Work Practice

The high levels of suicidality observed are consistent with studies from other locations (Dhejne et al., 2011; Grant et al., 2010; Mathy, 2002; McNeil et al., 2012; Motmans et al., 2010; Whittle et al., 2007; Whittle et al., 2008), and reflect serious and immediate concerns for trans people, their families and their communities. Importantly, suicidality varied widely depending on participants’ experiences of transphobia and transphobic violence, the social and familial support available to them, and their stage of transition. While some researchers have claimed that it is the very fact of being trans which leads to poor mental health (Steiner et al., 1985), our findings suggest that suicidality within trans communities is a social justice issue. The Canadian Association of Social Workers (CASW) enshrines the “pursuit of social justice” as one of six core values in the CASW (2005) Code of Ethics, requiring that social workers strive toward the elimination of discrimination, the equitable distribution of resources to meet basic needs, and the provision of services to protect individuals from harm (p.5). Our findings indicate that the conditions for social justice are absent for Ontario trans communities. We discuss implications for social work research, education, policy and direct practice.

For social work researchers and educators, it is important to intervene in forms of marginalization that impact trans people with or without direct discrimination. Namaste (2000) introduced the concept of erasure to describe the way transsexuality is managed in culture and institutions, describing it as “a condition which ultimately inscribes transsexuality as impossible” (p.4-5). Bauer et al. (2009) identified two interrelated forms of erasure: informational and institutional erasure. As they note, the existence of trans people is often not made visible in informational systems such as research studies, needs assessments and curricula. This in turn reinforces institutional erasure, the active or passive erasure of trans people’s needs from the policies and practices of institutions. Simply put, programs are not created to serve people who do not exist; thus the ability of trans people to obtain just and equitable access to services, is dependent on the collection and distribution of accurate information about their lives. It is the responsibility of researchers and organizations to provide methods for trans people to identify themselves on surveys and intake forms. It is the responsibility of social work educators to gather and impart information about the needs of trans communities.

These findings also indicate a number of policy arenas in which social work advocacy is needed, including human rights legislation, access to medical transition, and organizational policy. Given the high levels of violence and discrimination that trans people face, explicit human rights protections are important for reducing vulnerability. While progress has been made, there remains a need to advocate for explicit protections at the federal level, as well as within all provinces and territories. In addition, at the organizational level, there is a need for access and equity policies to protect the rights of trans clients and staff. Given the strong correlation between transphobic violence and suicide, it is imperative that social workers advocate for equitable access to services such as rape crisis centers and shelters. There is an ongoing history of barriers for trans people requiring these services, in particular for trans women seeking access to women’s services (Namaste, 2000). Social workers must ensure that the injustice trans people face in society is not mirrored at the level of service provision.

An additional policy issue in need of advocacy is access to medical transition care. Suicide prevalence in our findings was clearly linked to participants’ stage of medical transition with those at the highest risk being those who were planning to transition but had not yet begun, and the lowest being among those who had completed a medical transition. These findings indicate that it is crucial to dismantle barriers to accessing transition tools (hormones and surgeries). Further, it is important to reconsider the role of imposed delays such as the “real life experience”, meant to establish readiness for transition. Though mental health professionals are often concerned to ensure that trans people are emotionally stable prior to being approved for transition, our findings indicate the need to consider that for some trans people, access to transition may potentially be a basic need, and thus necessary for achieving such stability.

For social workers in direct practice with families and youth, these findings have many implications. As noted, both suicide consideration and attempts were significantly higher among trans youth, with two-thirds of reported first-time suicide attempts occurring prior to age 20. There is a need for social work practitioners to be aware of these risks and to gain knowledge of emerging options to support trans youth, including community groups and resources as well as access to puberty suppressant hormones and early transition-related care. It is also clear, based on the results of this analysis and a separate youth-specific analysis (Travers et al., 2012), that family support plays a key protective role for young people. Though many major urban centres now offer services for trans or LGBTQ youth, very few services are equipped to provide in-depth support to parents who are often struggling to process their own transphobia and complex emotional reactions to a trans child. Social workers can strengthen vital parent-child bonds by acting as supports to parents as they learn to embrace their child. Lastly, for social workers practicing in all contexts, our findings draw a strong link between trans people’s available social support and suicidality. Directing efforts toward building empowered and resilient families and communities will serve as much needed protection.

In closing, the high frequency of suicidality among trans people demands that action be taken. This study joins a growing body of literature calling for a social work response to the conditions of social injustice within trans communities (Hartley et Whittle, 2003; Mallon, 1999; Morrow et Messinger, 2006; Pyne, 2011; Sakamoto et al., 2009). These results speak to the need to include trans people within research, educational curricula, human rights legislation and organizational policy. In addition, these results speak to the importance of advocating for trans people’s access to transition-related care, for fostering their acceptance within families and for working toward social justice for all members of trans communities.

Parties annexes

Remerciements

The research presented here was supported by an operating grant from the Canadian Institutes of Health Research, Institute of Gender and Health (Funding Reference #MOP-106478). Partners in Trans PULSE included the Sherbourne Health Centre (Toronto), The 519 Church Street Community Centre (Toronto), The University of Western Ontario (London), Wilfrid Laurier University (Waterloo), the Ontario HIV Treatment Network, and Rainbow Health Ontario. The Trans PULSE Steering Committee members were Greta Bauer, Robb Travers, Rebecca Hammond, Anjali K, Matthias Kaay, Jake Pyne, Nik Redman, Kyle Scanlon, and Anna Travers. The authors wish to acknowledge Ayden Scheim for assistance with manuscript preparation, the 16 Community Engagement Team members and other contributors who aided survey development, the 85 trans people and 4 allies who contributed to the first phase of the study that shaped this survey, and the 433 trans people who shared their experiences through their survey participation. The authors also wish to respectfully acknowledge Kyle Scanlon, a cherished member of our research team who we lost to suicide in 2012.